A nurse is caring for a toddler who is 24 hr postoperative following a cleft palate repair.
Which of the following actions should the nurse take?
Apply bilateral wrist restraints.
Implement a soft diet.
Administer opioids for pain.
Offer fluids through a straw.
The Correct Answer is C
A. Applying bilateral wrist restraints is not a standard intervention after cleft palate repair.
Restraints should be used judiciously and with clear indications to prevent injury.
B. The baby can start feeding normal diet after 24hrs
C. Administering opioids for pain is an appropriate action by the nurse. Opioids control pain in the immediate postoperative period are followed by administration of acetaminophen PRN.
D. Offering fluids through a straw is contraindicated after cleft palate repair, as it can disrupt the healing process and increase the risk of complications. Sippy cups or other appropriate utensils should be used.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
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Correct Answer is C
Explanation
A. Collecting all urine may be a part of the diagnostic process, but it is not the primary warning associated with Wilms' tumor.
B. Contact precautions are not typically required for Wilms' tumor.
C. The warning "Do not palpate abdomen" is crucial because palpation can potentially disrupt the tumor and cause hemorrhage.
D. No venipuncture or blood pressure in the left arm is not a typical precaution associated with Wilms' tumor. The emphasis is on avoiding abdominal palpation to prevent trauma to the tumor.
Correct Answer is C
Explanation
A. Nausea and vomiting are more commonly associated with hyperglycemia or diabetic ketoacidosis, not hypoglycemia.
B. The onset of low blood glucose usually occurs quickly, not slowly.
C. Feeling shaky is a common symptom of hypoglycemia, and the parents' recognition of this symptom is indicative of an understanding of the teaching.
D. Sweating is also a symptom of hypoglycemia, not hyperglycemia.
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